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Peer-reviewedCC BYAJNR: American Journal of Neuroradiology

Characterization of Perfusion Scotoma in Acute Ischemic Stroke after Endovascular Treatment

  • Giorgio Busto1
  • Umberto Pensato2,3
  • Johanna M. Ospel4
  • Ilaria Casetta5
  • Francesco Loverre1
  • Giorgio U. Marcello1
  • Anna Poggesi6
  • Simona Marcheselli2,3
  • Andrea Ginestroni1
  • Alessandro Padovani7
  • Andrea Morotti7
  • Enrico Fainardi1,8
8 affiliations
  1. 1From the Neuroradiology Unit, Department of Radiology (G.B., F.L., G.U.M., A.G., E.F.), Careggi University Hospital, Florence, Italy
  2. 2Department of Biomedical Sciences (U.P., S.M.), Humanitas University, Milan, Italy
  3. 3Department of Neurology (U.P., S.M.), IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
  4. 4Department of Radiology (J.M.O.), University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
  5. 5IRCCS San Camillo Hospital (I.C.), Venice, Italy
  6. 6Stroke Unit (A. Poggesi), Careggi University Hospital, Florence, Italy
  7. 7Department of Clinical and Experimental Sciences, Neurology Unit (A. Padovani, A.M.), University of Brescia, Brescia, Italy
  8. 8Department of Experimental and Clinical Biomedical Sciences, Neuroradiology Unit (E.F.), University of Florence, Florence, Italy
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Abstract

PURPOSE: CT-perfusion (CTP) may underestimate the size of the ischemic core, a phenomenon known as “perfusion scotoma”. We aimed to investigate the prevalence of perfusion scotoma, characterize its baseline predictors, and explore its association with functional outcomes in a real-world population of stroke patients treated with endovascular treatment (EVT). METHODS: Data were obtained from a prospective EVT registry, selecting patients with successful recanalization (final mTICI ≥2b), a good quality baseline CTP, and an available 24-hour non-contrast CT. Ischemic core underestimated volume (ICuV) was calculated as the difference between follow-up infarct volume and CTP-estimated ischemic core. The primary outcome was the presence of perfusion scotoma, defined as ICuV ≥10 mL. Baseline characteristics with p value <0.20 in univariable comparisons were entered in a backward stepwise, multivariable logistic regression analysis to identify factors independently associated with perfusion scotoma. RESULTS: A total of 464 patients of 672 (69%) were included in the analysis. The median age was 74 years (IQR=68-83), 215 (46.3%) were males, and 116 (25%) had a perfusion scotoma. Perfusion scotoma was independently associated with male sex (adjusted OR 1.62 [95%CI 1.01-2.51]; p=0.04), more distal site of occlusion (adjusted OR 1.60 [95%CI 1.10-2.34]; p=0.01; per each 1-point increase: terminal ICA to M1 to M2), lower ASPECTS at admission (adjusted OR 0.64 [95%CI 0.54-0.76]; p<0.001; per each 1-point increase), and longer onset-to-CT time (adjusted OR 1.05, [95%CI 1.01-1.10]; p=0.03; per each 1-hour increase). The optimal onset-to-CT time cutoff to distinguish between patients without and with perfusion scotoma was 420 minutes. Perfusion scotoma was associated with 90-day ordinal mRS (adjusted common OR [acOR] 3.16 [95%CI 2.12–4.76]). CONCLUSION: Perfusion scotoma occurred in 1 out of every 4 patients. Baseline predictors included male sex, lower ASPECTS, more distal vessel occlusion, and longer onset-to-CT time. Perfusion scotoma was associated with poorer functional outcomes.

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Cite

BibTeXRIS
BibTeX
@article{busto2026characterization,
  title = {{Characterization of Perfusion Scotoma in Acute Ischemic Stroke after Endovascular Treatment}},
  author = {Giorgio Busto and Umberto Pensato and Johanna M. Ospel and Ilaria Casetta and Francesco Loverre and Giorgio U. Marcello and Anna Poggesi and Simona Marcheselli and Andrea Ginestroni and Alessandro Padovani and Andrea Morotti and Enrico Fainardi},
  journal = {AJNR: American Journal of Neuroradiology},
  year = {2026},
  month = nov,
  doi = {10.3174/ajnr.a9321},
  url = {https://doi.org/10.3174/ajnr.a9321},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Characterization of Perfusion Scotoma in Acute Ischemic Stroke after Endovascular Treatment
AU  - Giorgio Busto
AU  - Umberto Pensato
AU  - Johanna M. Ospel
AU  - Ilaria Casetta
AU  - Francesco Loverre
AU  - Giorgio U. Marcello
AU  - Anna Poggesi
AU  - Simona Marcheselli
AU  - Andrea Ginestroni
AU  - Alessandro Padovani
AU  - Andrea Morotti
AU  - Enrico Fainardi
PY  - 2026
DA  - 2026/11/06
JO  - AJNR: American Journal of Neuroradiology
DO  - 10.3174/ajnr.a9321
UR  - https://doi.org/10.3174/ajnr.a9321
AB  - PURPOSE: CT-perfusion (CTP) may underestimate the size of the ischemic core, a phenomenon known as “perfusion scotoma”. We aimed to investigate the prevalence of perfusion scotoma, characterize its baseline predictors, and explore its association with functional outcomes in a real-world population of stroke patients treated with endovascular treatment (EVT). METHODS: Data were obtained from a prospective EVT registry, selecting patients with successful recanalization (final mTICI ≥2b), a good quality baseline CTP, and an available 24-hour non-contrast CT. Ischemic core underestimated volume (ICuV) was calculated as the difference between follow-up infarct volume and CTP-estimated ischemic core. The primary outcome was the presence of perfusion scotoma, defined as ICuV ≥10 mL. Baseline characteristics with p value <0.20 in univariable comparisons were entered in a backward stepwise, multivariable logistic regression analysis to identify factors independently associated with perfusion scotoma. RESULTS: A total of 464 patients of 672 (69%) were included in the analysis. The median age was 74 years (IQR=68-83), 215 (46.3%) were males, and 116 (25%) had a perfusion scotoma. Perfusion scotoma was independently associated with male sex (adjusted OR 1.62 [95%CI 1.01-2.51]; p=0.04), more distal site of occlusion (adjusted OR 1.60 [95%CI 1.10-2.34]; p=0.01; per each 1-point increase: terminal ICA to M1 to M2), lower ASPECTS at admission (adjusted OR 0.64 [95%CI 0.54-0.76]; p<0.001; per each 1-point increase), and longer onset-to-CT time (adjusted OR 1.05, [95%CI 1.01-1.10]; p=0.03; per each 1-hour increase). The optimal onset-to-CT time cutoff to distinguish between patients without and with perfusion scotoma was 420 minutes. Perfusion scotoma was associated with 90-day ordinal mRS (adjusted common OR [acOR] 3.16 [95%CI 2.12–4.76]). CONCLUSION: Perfusion scotoma occurred in 1 out of every 4 patients. Baseline predictors included male sex, lower ASPECTS, more distal vessel occlusion, and longer onset-to-CT time. Perfusion scotoma was associated with poorer functional outcomes.
SN  - 0195-6108
SN  - 1936-959X
ER  -